Interdisciplinary Walking Rounds: A Key Strategy for…

By Toni Cesta, Ph.D., RN, FAAN

INTRODUCTION

In last month’s edition of Case Management Insider, we began exploring the evolving world of interdisciplinary care rounds. “State of the art,” as defined by The Joint Commission and the Institute for Healthcare Improvement, is to have some form of bedside or walking rounds. These bedside rounds provide a mechanism for engaging not only the entire healthcare team, but also the patient and family, in the planning process. In order for rounds to be most effective, they must include a script that all team members are familiar with. By using a script, the rounds are more likely to stay on track and within the time allotted. Last month we reviewed the “talking points” for such rounds, including the specific elements to be discussed. This month we will continue our discussion of rounds, including the roles of specific team members.

DAILY GOALS

One element of the rounding process is to develop, revise, or complete components of the patient’s plan of care. The care planning session that takes place on rounds includes a discussion of the patient’s daily goals. Daily goals provide a framework for the team and for the patient in terms of management of the patient’s progress toward their goals and toward discharge. The process should take place as follows:

determine the key goals for that day,
document the goals so that they are readily accessible to the care team, the patient, and the family,
provide feedback and reflection on the progress toward the goals every day,
revise/reset the goals as needed based on the team’s review, and
update the patient and family.

ENGAGING THE PATIENT AND FAMILY

One of the most powerful differences between bedside rounds and rounds that take place in a conference room is the opportunity to include the patient and family in the process. This is the most significant difference between these two types of rounds. Before including the patient or family in the rounding process, it is advised that, whenever possible, you orient them to the process first. During an orientation discussion, you should discuss the focus of the rounds. Explain that the rounds are used as an opportunity for the healthcare team to meet with the patient and family and discuss the daily goals and goals for the hospitalization. It also provides an opportunity for the patient and family to ask any questions or get any clarification they might need regarding any components of the healthcare plan.

The next area to be discussed during the orientation discussion should be the routine, or how the healthcare team will present themselves at the bedside. Finally, the expectations for rounds should be explained. The patient and family should understand that rounds last for about 60 to 90 seconds. Should the patient or family need additional or more in-depth information, someone from the team will return to the patient’s room after the conclusion of rounds. They should expect each team member to provide some information on their care, or a single representative will speak, depending on how your hospital structures the rounds.

ENTERING THE PATIENT ROOM

The day and time of the rounds should be posted in the patient’s room. When the team enters the room they should always start with a brief introduction that includes names, titles, and the purpose of rounds. The patient and family should be encouraged to participate.

PREPARING AND ATTENDING ROUNDS

Each member of the care team plays a distinct role on rounds. That role begins with preparation prior to the start of the rounds each day. On page 9 is a table outlining each team member’s pre-rounds, rounds, and post-rounds responsibilities.

TALKING POINTS FOR ROUNDS

The team should understand their roles on rounds and the focus of their contribution to the patient discussion. Rounds must be mandatory and take place at the same time each day. Below are some examples of talking points for team members:

THE PHYSICIAN AND/OR STAFF NURSE

the plan of care;
the expected outcomes of care;
the expected length of stay;
discharge plan;
barriers to care.

RN CASE MANAGER

status of discharge plan;
barriers to care and to discharge;
any reimbursement issues;
the expected length of stay.

SOCIAL WORKER

any psychosocial issues;
any barriers to discharge.

RESPIRATORY THERAPY/PHYSICAL THERAPY/NUTRITION

any interventions and goals of care;
any barriers to care.

Respiratory therapy, physical therapy, and nutrition team members should participate on rounds on patient care units where their specialties are areas of focus. For example, physical therapy should participate on units such as orthopedic surgery, neurosurgery, and geriatrics. Respiratory therapy should be active on units where there are ventilators or where respiratory patients are cohorted. Nutrition should be active on long-term units and geriatric units.

Documentation of rounds must take place in a timely manner, meaning either during rounds or immediately afterward. The best way to accomplish this is to use some standard format such as a checklist.

THE IMPACT OF INTERDISCIPLINARY CARE ROUNDS

In addition to the rewards associated with bringing care planning to the bedside, rounds can have other equally important positive effects. Below is a list of many of the elements that can be improved via an effective rounding process:

improved communication and teamwork across caregivers,
reduced duplication and redundancy,
reduced length of stay,
improved patient flow,
reduced errors,
expedited discharge planning,
increased collaboration and satisfaction among all members of the team, and
improved knowledge of the patient’s care plan.

These positive outcomes can have an effect on your hospital in a number of categories. Among these is the Medicare Spending per Beneficiary measure, which scores the hospital based on length of stay and cost per case for selected diagnoses. By improving communication and reducing duplication and redundancy, cost reductions can be achieved. In addition, cost can also be positively affected by improving patient flow and reducing errors. Rounds have also been shown to reduce errors in medical ordering due to increased communication and collaboration. The team can also discuss readmission root causes and create a plan of action to reduce them for the patient. While this outcome has not yet been measured as it specifically relates to rounding, enhanced communication in general has been shown to reduce readmission rates.

Case management roles can be equally enhanced by an effective rounding process. When collaboration is improved among all caregivers, avoidable delays can be reduced. At the same time, length of stay can be positively affected. Finally, due to the improved communication among and between team members, the discharge planning process can be expedited with fewer delays in the process. In fact, all of the expected outcomes of an improved rounding process will have a positive impact on case management and the work of case managers.

While these positive effects are undeniable, there are other outcomes that may be more easily measured. These indicators can be tracked on a “rounding dashboard” or “report card” so that team members can see the positive effect that the new rounding process is having. The following is a list of such indicators:

length of stay;
ICU patient days;
ventilator days;
number of pharmacy changes such as discontinuing antibiotics;
patient and family satisfaction;
number of discharge delays.

Someone on the team will need to keep track of these outcome measures and populate the dashboard. A monthly accounting is best, as more frequent measurements will not show enough change. With less frequent accounting, the team will not be able to change processes should the data indicate a lack of improvement in a particular area. Your hospital may want to add additional or other indicators to your dashboard depending on the original goals that you set for your rounding process.

OTHER MEASURES TO HOLD THE GAIN

It is critical that the team stay on track and in order to be sure that they are, there are other measures to manage as well as those mentioned earlier. Administratively, someone should do a periodic monitoring of the following:

number of days per week that rounds occur,
number of disciplines involved,
percentage of patients with a documented daily goal in their record,
the average time spent with each patient, and
start time.

These measures are critical to the ongoing success of the rounds. Any of these elements can sustain slippage if not routinely monitored. For example, the start time may begin to get later and later, or some disciplines may stop attending. The time spent with patients may get too long over time if team members go off-script. This type of monitoring should be done by the discipline administratively responsible for rounds. This may be nursing, hospitalists, or others. It may be better to have someone who doesn’t typically attend rounds perform this assessment. This fresh set of eyes may pick up issues that those attending on a daily basis may not pick up, or may not be aware of. This can be done ad hoc and should not be scheduled or announced.

THE ULTIMATE GOALS OF BEDSIDE ROUNDS

Healthcare continues to struggle with wide variation among providers, hospitals, systems, and states. Variation leads to increased cost and reduced quality of care. By having the team rounds together, each team member can understand and aim to reduce variation in terms of how they manage their patient care and how they deliver that care. In addition, the handoff of communication should be seen as a tool that professionals use to ensure that patient care is not duplicated and that things do not fall between the cracks. Good communication is every professional’s responsibility. Finally, it is during handoff communication that issues of quality of care, such as delays, can be caught early and addressed in a timely manner. These kinds of vulnerabilities will affect cost and quality but can be caught early during rounds. Ultimately, it is the engagement of the patient and the family that makes bedside rounds a winner. Lack of communication is a leading cause of dissatisfaction for patients. It leads to errors and to readmissions when patients are not informed and/or do not understand the role that they need to play in their own care.

TRANSITIONING TO WALKING ROUNDS

The best way to make a smooth transition to walking rounds is to leverage your existing rounds. You may have rounds in a conference room that work well and are well attended. You can take this format to the bedside and utilize the parts of the sitting rounds that were working well. Or you may have a good walking rounds process already in place in some hospital locations such as the critical care units. In either case, take the best of what you have and use it as a strategy to bring your rounds to the patient bedside. Be sure to include all stakeholders in the planning and implementation process. Start slowly and add units over time. Pick initial units that you think will be successful early on. Early success will motivate other units to want to participate as well. Roll them out as quickly or as slowly as you think will work best, but keep the momentum going!

	Pre-Rounds	Rounds	Post-Rounds
Provider	Listen to last 24-hour patient update. Discuss working diagnosis. Enter any patient orders. Review preliminary plan for discharge, meds, tests.	Sit next to patient. Introduce team — name and discipline. Interview patient and get his/her story. Discuss plan of care, test results, next steps, other recommendations. Answer any questions.	Enter orders, clarify any issues. Enter progress notes or dictation. Call consulting physicians, family regarding test results. Summarize expectations to team members.
Resident	Present patient case to attending physician/team. Update team on patient conditions. Give recommendations for plan of care. Enter any orders, including medications.	Support attending physician during assessment. Help answer any questions.	Enter orders as needed for patients. Enter progress notes. Call consulting physicians as directed by attending. Discuss med rec with pharmacist.
Staff RN	Review patient progress over past 24 hours. Focus on any abnormal findings. Review any patient/family concerns. Identify any barriers to patient discharge. Review any issues such as activity, Foley, IV, wound vac.	Bring laptop or other device to patient room. Listen to conversation with patient. Ask/answer questions from patient and team. Note orders to be placed later.	Verify orders. Discuss and implement medication monitoring. Make decisions about any remaining concerns. Document outcome of rounds.
Case Manager	Review admission status — inpatient vs. observation. Review case management admission assessment. Review initial discharge plan and insurance. Review expected length of stay and discharge date.	Discuss expected length of stay and discharge day. Discuss discharge plan — or updated plan — with patient and family. Identify any additional patient education needs. Identify any social work triggers for referral to social work.	Clarify next steps based on patient’s goal achievement. Document any changes to discharge plan. Refer to social work as needed.
Registered Nurse	Review daily progress notes. Review medication profile, medication history, and med rec. Review PRN med use. Discuss medication concerns and abnormal lab/culture findings.	Listen to conversation. Ask/answer any patient questions. Note orders to be placed later.	Verify orders. Discuss and implement medication monitoring. Make decisions about any remaining med concerns. Document progress notes.
Clinical Documentation Improvement Specialist	Review patient information in medical record Listen to overview of patient	Listen to patient status Consider any questions to ask physician	Clarify and identify any additional diagnoses/conditions — query if needed Review physician documentation for accuracy Provide any needed physician education

SUMMARY

The role of interdisciplinary care rounds has never been more vital to the success of healthcare institutions. As the Centers for Medicare & Medicaid Services continues to strive to equate reimbursement with quality of care, hospitals will need to find new ways to deliver care that achieve these goals and have a positive effect on the bottom line. The notion of rounds is not a new one, but taking rounds to the bedside on all patient care units is. Critical care areas have used this format for years, but it is now time for this effective process to be taken to the bedside of each and every hospitalized patient.

Interdisciplinary Walking Rounds: A Key Strategy for Improving Case Management Outcomes – Part 2